MERS-CoV recently re-emerged in Qatar, Saudi Arabia, its feasible global health risks amid FIFA world cup 2022 and salient counteracting strategies – an update
Authors: Hitesh Chopra, Md. Aminul Islam, Deepak Chandran, Talha B. Emran, Nahed A. El-Shall, Jaffar A. Al-Tawfiq, Kuldeep Dhama
Journal: International Journal of Surgery (2023)

Dear Editor, The 2022 Fédération Internationale de Football Association (FIFA) World Cup in Qatar has sparked a global craze for the beautiful game. Millions of supporters from all over the globe are expected to attend this worldwide football event, despite the fact that it is being organized in the shadow of two public health catastrophes [the coronavirus disease 2019 (COVID-19) pandemic and the monkeypox illness, which has just been called 'Mpox']. It is the first time the World Cup has been hosted in the Arab and Muslim worlds, and the second time it has been held wholly in Asia (following the 2002 tournament in South Korea and Japan), and it will take place in Qatar between 20 November and 18 December 20221. Despite all this excitement, health experts supported by the WHO have raised concerns about the risk of a deadlier virus epidemic during the FIFA World Cup. On 16 November 2022, WHO reported an outbreak of Camel flu or Middle East respiratory syndrome (MERS) in Saudi Arabia2. The International Health Regulations (IHR) National Focal Point of the Kingdom of Saudi Arabia has reported four more cases of MERS-CoV after the previous Disease Outbreaks News on Middle East respiratory syndrome coronavirus (MERS-CoV) in Saudi Arabia was released on 7 April 2022. Four instances of locally acquired MERS-CoV infection were reported between 29 December 2021 and 31 October 2022 in the areas of Riyadh (two cases), Gassim (one case), and Makka Al Mukarramah (one case). The real time-PCR was used for the laboratory confirmation of the instances. All the patients were regular people who were not in the medical field but who were experiencing symptoms like fever, cough, and shortness of breath. Three of the people who became ill had recently been in touch with dromedary camels or had raw milk from one during the previous 2 weeks. There were three male instances, and the ages of the patients ranged from 23 to 74. The first case of MERS-CoV was identified in 2012, and since then, 2601 cases and 935 fatalities have been recorded from 27 countries across all six WHO regions. The Kingdom of Saudi Arabia has reported the largest number of MERS-CoV cases (n=2193; 84%), with 854 fatalities as a direct consequence3. Though around 36% of MERS patients have died, this may be an underestimate since present monitoring methods may overlook mild instances of MERS-CoV, and case fatality rates are only recorded among laboratory-confirmed cases. MERS-CoV is spread from dromedary camels to humans via zoonotic transmission. The MERS-CoV virus has been shown to spread from person to person. Until now, human-to-human transmission has only been documented during brief encounters, such as those that take place in intimate relationships or in healthcare facilities. Human-to-human transmission has been low outside of clinical settings. The six strains of the RNA virus known as MERS-CoV all have envelopes. The MERS-CoV virus is a member of the gamma genus of coronaviruses that can cause zoonotic illnesses in both humans and animals4. Droplet transmission, close patient contact, and camel exposure are all potential routes of transmission for MERS-CoV. The months of March through May have the highest rates of illness transmission. Subclinical infection with respiratory and renal symptoms often takes 3–4 days to develop5. Depending on the severity of the infection, MERS-CoV may cause anything from no symptoms at all (asymptomatic) to severe acute respiratory illness and even death. Fatigue, coughing, and difficulty breathing are the classic symptoms of MERS-CoV infection. Although pneumonia is often diagnosed, it is not always present. Reports of gastrointestinal distress, such as diarrhea, have also surfaced. Patients with immunosuppression or co-morbidities such as obesity, diabetes, cardiovascular disease, lung disease, and acute renal failure are at increased risk for developing severe symptoms. MERS can lead to a kind of pneumonia that is extremely dangerous. Both hypoxia damage and renal infection contribute to the high prevalence of acute renal failure in these patients. Higher levels of DPP4 expression in the kidney may contribute to the increased prevalence of kidney infections6,7. Intensive care unit patients with life-threatening illnesses sometimes need to be ventilated mechanically to keep them alive. Disease caused by the virus seems to be more severe among the elderly, those with compromised immune systems, and those who already suffer from conditions including renal failure, cancer, chronic lung disease, and diabetes8. There were 2600 instances of laboratory-confirmed MERS-CoV infection reported worldwide to WHO between September 2012 and 17 October 2022, with 935 fatalities. The majority of these incidents have happened in Arabian Peninsula nations. May 2015 was the largest epidemic outside of the Middle East, with 186 confirmed cases (185 in the Republic of Korea and one in China) and 38 fatalities; however, the index patient in that outbreak had visited the Middle East. The overall risk assessment has not changed as a result of the four instances being reported. The WHO anticipates further MERS-CoV infection cases to be reported from the Middle East and/or other countries where MERS-CoV is circulating in dromedaries, and that cases will continue to be exported to other countries by individuals who were exposed to the virus through contact with dromedaries or their products (e.g. consumption of camel's raw milk), or in a healthcare setting. Since the commencement of the current COVID-19 epidemic, the number of MERS-CoV cases reported to WHO has significantly decreased9. This is probably due to the fact that testing and identification of MERS-CoV infections have decreased as a consequence of priority being given to epidemiological monitoring operations for COVID-19. There will be fewer opportunities for human-to-human transmission of MERS-CoV because of the measures taken during the COVID-19 pandemic to reduce severe acute respiratory syndrome coronavirus 2 transmission (such as mask-wearing, hand hygiene, physical distancing, improving the ventilation of indoor spaces, respiratory etiquette, stay-at-home orders, reduced mobility). However, these precautions probably did not slow the spread of MERS-CoV in dromedary camels. Even though there has been a decline in the number of secondary MERS cases recorded, zoonotic transmission still poses a threat. Delays in detecting the early signs of MERS-CoV infection, sluggish triage of suspected cases, and delays in adopting infection, prevention, and control (IPC) measures have all been linked to the spread of the virus from human to person in hospital settings. Preventing the transmission of MERS-CoV from patient to patient in healthcare settings makes IPC measures paramount. Standard precautions should be used consistently by all healthcare professionals with all patients at all times and in all healthcare settings. Care for suspected or confirmed cases of MERS-CoV infection necessitates additional precautions, including the use of droplet and contact precautions, as well as eye protection, and additional airborne precautions are required when performing aerosol-generating procedures or in settings where aerosol-generating procedures are conducted. Gowns, gloves, goggles, or a face shield, as well as a respirator equivalent to a disposable N95 filtering facepiece respirator, should all be used for safety. A high-efficiency particulate air filter or negative pressure rooms should be used for patients with MERS. High-risk treatments, such as bronchoscopy, intubation, nebulization therapy, or tracheal suction, necessitate the use of airborne preventive measures with at least six air changes per hour in treatment rooms. These suggestions are backed by data and have been successfully implemented in hospitals across the affected regions10,11. Human-to-human transmission of MERS-CoV may be prevented by early identification, case management and isolation of patients, follow-up and quarantine of contacts, as well as proper IPC measures in a healthcare context and public health awareness. Epidemiological strategies for disease control aim to lessen the likelihood of an outbreak spreading from animals to humans by means such as faster diagnosis, better isolation procedures, and more thorough follow-ups with patients. The WHO and its allies stress the need of finding possible cases, decreasing zoonotic transmission, providing safe and effective treatment, and decreasing morbidity and mortality in healthcare facilities12. People with preexisting illnesses such as diabetes, renal failure, chronic lung disease, and immunosuppression tend to be more severely affected by MERS-CoV. Therefore, persons with these preexisting diseases should exercise caution while visiting farms, markets, racing tracks, or slaughterhouses where the virus may be spreading since close contact with animals, especially dromedaries, might exacerbate or even exacerbate symptoms. It is important to practice good hygiene in general, so be sure to wash your hands before and after petting animals and stay away from those that seem to be unwell. Recent trials suggest that combination antivirals may be helpful in extremely unwell patients, but no particular antiviral therapies exist. Preventing hospital-acquired infections like MERS-CoV requires prompt diagnosis and the adoption of infection control measures. In order to prevent MERS, it is important to refrain from eating raw or undercooked animal products, to practice safe hygiene around dromedaries and in healthcare settings, to educate the public and train healthcare professionals on how to spot the symptoms, and to put in place effective control measures6,13. Various vaccine candidates have been created and research into new vaccines has begun. A vaccine based on modified live attenuated virus (MVA) and expressing the MERS-CoV glycoprotein is one option. It was successful in dromedary camels and is likely to be so in other types of camels as well14. Due to the success of this vaccine, the benefits of preventing the spread of the disease in its animal reservoir have been discussed, lending credence to the One Health approach, which is gaining widespread support throughout the world. The ultimate goal of the next human clinical trials for this vaccine is to protect healthcare personnel to prevent nosocomial spread, as well as to protect contacts of sick persons. Ethical approval Not applicable. Sources of funding None. Conflicts of interest disclosure All authors report no conflicts of interest relevant to this article. Author contribution H.C. – conceptualization, data curation, investigation, writing – original draft, and writing – review and editing; M.A.I. – validation and reviewing; D.C. – validation and reviewing; T.B.E. – validation and reviewing; N.A.E.-S. – validation and reviewing; J.A.A.-T. – validation and reviewing; K.D. – validation and reviewing. Research registration unique identifying number (UIN) None. Guarantor Md. Aminul Islam, COVID-19 Diagnostic Lab, Department of Microbiology, Noakhali Science and Technology University, Noakhali 3814, Bangladesh; Advanced Molecular Lab, Department of Microbiology, President Abdul Hamid Medical College, Karimganj, Kishoreganj 834001, Bangladesh. Data statement The data in this correspondence article is not sensitive in nature and is accessible in the public domain. The data is therefore available and not of a confidential nature.